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The BACTEC 460 radiometric mycobacterial broth culture system has consistently demonstrated faster and increased recovery of Mycobacterium tuberculosis from respiratory specimens of patients with pulmonary tuberculosis than conventional culture methods. We thus questioned whether three sputa were still necessary to definitively diagnose pulmonary tuberculosis if the BACTEC radiometric culture system were in use. We performed a retrospective analysis of 430 sequential respiratory specimens submitted from 143 patients and from which M. tuberculosis had been recovered by in vitro culture and simultaneously assessed the diagnostic yield of acid-fast smear in this same cohort. M. tuberculosis was recovered from the first specimen for 117 (82%) of the 143 patients, from the second for 14 patients (10%; cumulative rate, 92%), and from the third for 12 patients (8%; cumulative rate, 100%). With the exception of those for bronchial brushings, recovery rates of M. tuberculosis were comparable for all respiratory specimen types (expectorated sputum, induced sputum, tracheal aspirates, bronchoalveolar lavage fluids). Only 46 (32%) of these 143 patients had acid-fast bacilli detected in smears; acid-fast bacilli were detected in the first submitted specimen for 44 patients (96%) and in the second for the remaining 2 patients (4%; cumulative rate, 100%). Culture- or smear-positive rates for sequential specimens obtained from AIDS patients were comparable to those for non-AIDS patients. Overall, the diagnostic culture yield of sequentially submitted specimens was not different from previously published studies in which the BACTEC radiometric culture system had not been used. Despite the documented enhanced ability of the BACTEC 460 radiometric mycobacterial culture system to recover M. tuberculosis more often and faster than conventional methods, three sequential respiratory specimens (regardless of type) were still necessary to definitively diagnose pulmonary tuberculosis.

In cases of advanced infection with human immunodeficiency virus, mycobacterial blood cultures are frequently used to diagnose disseminated infection with the Mycobacterium avium complex (MAC). However, no prospectively validated guidelines exist for the use of such cultures. In this study, a two-part model for predicting MAC bacteremia was developed and then validated prospectively. First, a CD4+ cell count of < or = 50/microL was used to predict bacteremia. Then, among patients with < or = 50 CD4+ cells/microL, the documentation of fever on more than 30 days during the preceding 3 months, a hematocrit of < 30%, or a serum albumin concentration of < 3.0 g/dL was used to predict bacteremia. This model had a sensitivity of 89% and positive and negative predictive values of 30% and 98%, respectively, for the identification of patients with bacteremia. Had the model been applied to patients in this study, the number of blood cultures performed would have decreased by 61%, but 11% of the positive cultures would have been missed. In short, this model can predict MAC bacteremia and can potentially guide the use of mycobacterial blood cultures.

Human infection with Ehrlichia chaffeensis, a recently identified bacterium included in the family Rickettsiaceae,1,2 results in an acute, generally self-limited, febrile illness associated with cytopenia and hepatic-enzyme abnormalities. Several hundred cases of E. chaffeensis infection have been recognized since 1986, although ehrlichiosis has not been described in patients infected with the human immunodeficiency virus (HIV). We report the course of a fatal seronegative ehrlichial infection in a woman with advanced HIV infection. The infection was diagnosed by light and electron microscopy, immunohistochemical techniques, and the polymerase chain reaction. The potential for successful antimicrobial treatment, combined with the possible absence . . .

Human immunodeficiency virus (HIV) is an important risk factor for invasive pneumococcal disease, but information on clinical course and infecting serotypes is limited. To help develop strategies to reduce the morbidity due to invasive pneumococcal disease, episodes of pneumococcal bacteremia were identified by retrospective review of microbiology records (November 1983-November 1987) at 10 San Francisco hospitals and, for patients 20-55 years old living in San Francisco, HIV antibody status was determined by review of medical records. Pneumococcal isolates from one hospital were serotyped. Of 294 patients with pneumococcal bacteremia identified, 32 (11%) had AIDS at the time pneumococcal bacteremia was diagnosed and another 43 (15%) were HIV-infected but did not have AIDS; 12 HIV-infected patients developed AIDS after the episode of pneumococcal bacteremia. The rate of pneumococcal bacteremia in AIDS patients was estimated to be 9.4/1000 patient-years. Serotypes of 27 (82%) of 33 pneumococcal isolates from HIV-infected patients and 107 (90%) from 119 patients without known HIV infection were among the 23 serotypes included in the currently available polysaccharide vaccine. The rate of pneumococcal bacteremia is approximately 100-fold greater in AIDS patients in San Francisco than rates reported before the AIDS epidemic, but more than half the episodes of pneumococcal bacteremia in HIV-infected patients occurred in patients without AIDS. Data on pneumococcal serotypes causing invasive disease in HIV-infected patients suggest that the current pneumococcal vaccine, if effective in this population, could provide significant protection against pneumococcal disease.

A case-control study was done to determine risk factors for Mycobacterium avium complex (MAC) disease in persons infected with human immunodeficiency virus (HIV) with < 50 CD4+ cells/mm3. In univariate analysis, cases (n = 83) had lower CD4+ cell counts than controls (n = 177) (median, 10 vs. 17/mm3; P < .001) and were more likely to have consumed hard cheese (odds ratio [OR], 5.44; 95% confidence interval [CI], 1.61-18.4) but were less likely to have taken daily showers (OR, 0.55; 95% CI, 0.33-0.94). In multivariate analysis, CD4+ cell count < 25/mm3 (OR, 3.58; 95% CI, 1.71-7.49) and consumption of hard cheese (OR, 5.63; 95% CI, 1.58-20.1) remained associated with disease, while daily showering (OR, 0.58; 95% CI, 0.28-0.88) remained protective. Increased risk for MAC disease in persons with HIV infection and low CD4+ cell counts is not associated with exposure to water or a variety of other environmental sources but may be associated with consumption of hard cheese.

Mycobacterium avium complex (MAC) is frequently isolated from the respiratory or gastrointestinal tract of patients with advanced human immunodeficiency virus (HIV) infection. Whether they are at increased risk of MAC bacteremia and whether culture of respiratory tract or stool specimens is useful for predicting bacteremia are unclear. HIV-infected patients with < or = 50 CD4+ cells/microL were prospectively studied. The risk of MAC bacteremia was approximately 60% within 1 year for patients with MAC in either the respiratory or gastrointestinal tract and was greater than for those without MAC in these sites (relative hazards for respiratory and gastrointestinal tract, 2.3 and 6.0; 95% confidence intervals, 1.1-4.6 and 2.5-14.6, respectively). Both respiratory tract specimen and stool culture had poor sensitivities (22% and 20%, respectively) but good positive predictive values (approximately 60%) for bacteremia. Symptomatic HIV-infected patients with MAC in the respiratory or gastrointestinal tract are at a substantial risk for developing MAC bacteremia; culture of these sites has limited usefulness as a screening test.

A mycobacterial DNA probe (designated X) was recently developed to help identify Mycobacterium avium complex (MAC) isolates that are nonreactive with probes specific for M. avium or Mycobacterium intracellulare. The prevalence of X probe-positive mycobacteria in clinical specimens and their role in causing disease is unknown. Using a DNA probe kit that includes the X probe, we characterized 100 consecutive clinical MAC isolates as M. avium, M. intracellulare, or X. Lysates from 81 of the isolates reacted with the M. avium probe, 13 with the M. intracellulare probe, 3 with the X probe, and 3 failed to hybridize with any of the probes. All three X-positive isolates were recovered from sputa of patients who were recent immigrants to the United States and who presented with hemoptysis. One isolate was from a Hispanic man infected with human immunodeficiency virus type 1 (HIV-1) and the other 2 were from Filipino patients with no HIV-1 risk factors. This study also showed a higher than expected number of M. intracellulare isolates from blood and cerebrospinal fluid of HIV-1-infected patients.

To determine the significance of cytomegalovirus (CMV) pulmonary coinfection with Pneumocystis carinii pneumonia in AIDS, we examined the association of long- and short-term survival and morbidity (as defined by length of hospital stay) with recovery of CMV from bronchoscopy specimens and an indirect measure of virus titer in bronchoalveolar lavage fluid (the time to develop CMV cytopathology in culture) in 111 patients diagnosed with a first episode of P. carinii pneumonia. Compared with 57 individuals from whom CMV was not isolated, the 54 individuals from whom CMV were isolated did not differ in baseline characteristics, long-term survival (213 versus 275 days, p = 0.97), acute death rate (19% in both, p = 1.0), or length of hospital stay (19.7 versus 21.1 days, p = 0.68). Also, the time to develop CMV cytopathology in culture did not correlate with acute or long-term survival. Our observations thus do not support the use of CMV-specific antiviral therapy in AIDS patients with P. carinii pneumonia who also have evidence of pulmonary CMV infection.

Pulmonary toxoplasmosis is a rarely recognized opportunistic infection in immunocompromised patients. A few case reports have described pulmonary toxoplasmosis in human immunodeficiency virus—infected patients in association withToxoplasma gondiicentral nervous system disease. We encountered six cases of pulmonary toxoplasmosis in human immunodeficiency virus—infected patients who presented with a protracted febrile illness, respiratory symptoms, and an abnormal chest roentgenogram in the absence of neurologic findings. No clinical or roentgenographic features distinguishedT gondiipneumonitis from more common opportunistic pulmonary infections. As the acquired immunodeficiency syndrome epidemic progresses, the presenting illnesses have evolved.Toxoplasma gondiimust be considered a potential cause of pulmonary disease during the evaluation of human immunodeficiency virus—infected patients with respiratory symptoms. (Arch Intern Med.1992;152:1073-1077)

The murine macrophage continuous cell line J774 was used to measure the ability of antimicrobial agents, either singly or in combination, to kill intracellular Mycobacterium avium complex. All of 14 strains of M. avium complex, isolated from patients with AIDS, grew inside J774 cells during an incubation period of 7 days. The susceptibility of macrophage-ingested M. avium complex to antimicrobial agents was determined by comparing the number of colony-forming units (cfu) of M. avium complex inside untreated macrophages at the time of drug addition with the number of cfu present in macrophages after treatment with drugs for 7 days. Simultaneous experiments were carried out in broth medium without macrophages in order to compare killing of free mycobacteria with killing of macrophage-ingested mycobacteria. Antimicrobial agents (rifampin, rifabutin [Ansamycin], ethambutol, ciprofloxacin, clofazimine, isoniazid, and amikacin) were tested using concentrations that are achievable in the serum of patients. Among drugs known to penetrate macrophages, there was 96.2% agreement in susceptibility test results between the broth experiments and the J774 experiments when single drugs were tested, but only 74% agreement when combinations of drugs were tested. Killing of M. avium complex inside J774 cells by any single drug was uncommon. However, killing in J774 cells occurred against 10 of 11 (91%) strains with the combination of rifabutin + ethambutol + ciprofloxacin and against all of seven strains tested with the combination of rifabutin + ethambutol + amikacin. Interpretive criteria of in vitro susceptibility data need to be developed so that these interpretations correlate with a predictable clinical response in patients.

Relationships among selected species of viridans streptococci were studied by using deoxyribonucleic acid (DNA)-DNA hybridization and biochemical and serological tests. The results of hybridization experiments performed with DNA immobilized on membrane filters and index DNA made radioactive with [methyl-3H]thymidine indicated that Streptococcus intermedius ATCC 27335T (type strain), Streptococcus constellatus ATCC 27823T, Streptococcus mitis ATCC 9895, “Streptococcus MG-intermedius” CDC SS 899, group F strain MGH 8153, and group F strain SFGH 879 are closely related to each other genetically, even though physiological tests indicated that this is a relatively heterogeneous group of organisms. The relative binding ratios for these six strains ranged from 60 to 99%, and the majority of values were greater than 85%, indicating that these strains should be considered members of the same species. Type strain ATCC 33399 (called S. mitis) is not a typical S. mitis strain based on biochemical test results, and only moderate relatedness (41%) was observed in hybridization experiments performed with a typical S. mitis strain (strain SS 429). Streptococcus sanguis I ATCC 10556T and S. sanguis II ATCC 10557 do not belong in the same species. A low relative binding ratio (13%) for these strains confirmed similar findings by previous investigators.

A procedure is described for preparing a permanent, stained slide of cells migrating from glass capillaries. The stained migration patterns are suitable for projection and photography, and allow the morphological study of cells involved in migration and migration inhibition. The slide represents a permanent record of the test or experiment performed.

Immunofluorescent staining and flow cytometric analysis have been investigated as means of studying the early stages of in vitro infection of Chlamydia trachomatis. The lymphogranuloma venereum strain of C. trachomatis was grown in vitro in L cells, fixed in p-formaldehyde, stained with fluorescein isothiocyanate (FITC)-conjugated monoclonal antibody to the chlamydial major outer membrane protein, and analyzed flow cytometrically. Infected cells stained 50-100 times more intensely than uninfected cells, and they could easily be discriminated by flow analysis. The number of infected cells and the fluorescence intensity of individual cells were proportional to the multiplicity of infection. The attachment of purified elementary bodies to L cells could be analyzed by immunofluorescence and flow cytometry. Cells exposed to 0.26 inclusion-forming units/cell could be discriminated from an unexposed population. Flow analysis of purified elementary bodies was possible after fluorescent staining with the aid of a laser-based cytometer and gating on low volume.

Water and animal tissue samples were obtained from sources in Tennessee, California, and Florida. Purified bacterial colonies were isolated and organisms identified. Fifty-eight isolates were recovered. Twenty-seven Gram-negative isolates were identified. Gram-positive organisms were of the coryneform group or Bacillus species. Antibiotic susceptibility testing showed that Aeromonas species were relatively resistant to a wide variety of anti-microbials, which included trimethoprim, cefazolin, and ampicillin. Antibiotics effective against more than 90% of Gram-negative isolates included ciprofloxacin, imipenem, ceftazidime, and trimethoprim-sulfamethoxazole. Freshwater Gram-positive organisms did not display any unexpected susceptibility features. Recommendations for treatment are based on sensitivity in culture and the potentially serious nature of infections caused by Aeromonas species.

Cellular immunity of 16 patients with systemic lupus erythematosus (SLE), as measured by the ability of their lymphocytes to proliferate in vitro following stimulation with mitogens and bacterial antigens, and by the ability of their polymorphonuclear neutrophils to reduce nitrobluetetrazolium dye, both spontaneously and upon stimulation, was found to be unimpaired by comparison with cells of 12 normal individuals. The relative frequency of responders to stimulation with human collagen and with several nuclear antigens, used over a wide range of concentrations and evaluated as a group, was significantly higher among patients with SLE. Antinuclear antibodies specific for DNA, RNA, or both, were found in all patients with SLE, but did not reflect the pattern of sensitization of lymphocytes to these antigens as measured by lymphocyte transformation.

An expandable plastic sponge is used to collect a uniform sample of fluid from the conjunctival sac. The uptake of fluid by the sponge and recovery of particles from the sponge is highly reproducible. The kinds of bacteria collected by the sponge were the same as those collected by a moistened swab. Collection with the sponge provides a rapid, precise, and highly reproducible method of sampling conjunctival bacteria in normal and inflamed eyes. This technique will be used in the study of the stages of disease severity and evaluation of the role of therapy in reducing bacterial counts.

It is clear that the group B streptococcus has become a major pathogen of young infants within the comparatively recent past. Further it is clear that, as with other endemic and epidemic pathogens, increasing clinical and laboratory experience brings to light variations not initially evident. In addition, therapy presumably effective in initial cases may not continue to be so. The following papers by coincidence were received over a relatively brief period of time. Hence, for emphasis of some of the problems related to this organism, they are presented as a group.

A task force* at the University of California, San Francisco, has developed infection-control guidelines for patients with the acquired immunodeficiency syndrome (AIDS). The task force included rep...

With the dramatic increase in the frequency of Pneumocystis carinii pneumonia associated with human immunodeficiency virus infection, there has been a need for more rapid and less invasive diagnostic techniques. Recent studies have shown that examination of induced sputum can establish the diagnosis of P. carinii pneumonia in about 55 percent of cases. To assess whether a recently developed indirect immunofluorescent stain using monoclonal antibodies was more sensitive than Giemsa or toluidine blue O stains in detecting P. carinii in sputum, we undertook two prospective studies. Of 63 patients at one institution from whom sputum specimens were obtained, 49 were ultimately given a diagnosis of P. carinii pneumonia, 46 of them by staining of sputum. The sensitivity of the three stains in detecting P. carinii was 45 of 49 (92 percent) for immunofluorescence; 37 of 49 (76 percent) for Diff-Quik (a Giemsa-type stain); and 39 of 49 (80 percent) for toluidine blue O. There were no false positive immunofluorescent stains. In a similar study of a series of 25 patients at another institution, a diagnosis of P. carinii pneumonia was made in 23 of 25 patients by staining of induced sputum. We conclude that examination of induced sputum is a rapid, sensitive, and inexpensive method for diagnosing P. carinii pneumonia and that indirect immunofluorescence is a practical and highly sensitive staining technique for establishing this diagnosis.

Ocean water and tissue samples were obtained from a variety of sources with phylogenetic and geographic diversity. Purified bacterial colonies were isolated and identification procedures were performed. A total of 67 isolates were recovered. Thirty-eight isolates belonged to the genus Vibrio and included six species. Twenty-four non-fermentative bacteria and four Gram-positive isolates were recovered. Antibiotic susceptibility testing showed that while the non-fermentative marine bacteria generally were susceptible to the antibiotics tested, marine Vibrio species were relatively resistant to a wide variety of antimicrobials. Antibiotics effective against all species included imipenem, trimethoprim/sulfamethoxazole, and chloramphenicol. Further recommendations for treatment are based on sensitivity in culture. Some isolates failed to grow in the medium used for susceptibility testing. Because commercial test kits may not yield accurate identifications of bacteria, the acquisition of antimicrobial susceptibility data gains added importance.

A severe rectal lesion due to Leishmania infection is described in an American-born homosexual man with the acquired immunodeficiency syndrome. The infection, which may have been venereally transmitted, responded to treatment with amphotericin B. There was no evidence of visceral leishmaniasis. The contribution of the patient's immunodeficiency to the development of the atypical cutaneous leishmanial lesion is unclear. The case may foretell increasing problems with protozoan infections in AIDS as the epidemic spreads to areas with endemic protozoan diseases.

Because of the reported use of yogurt douches for the treatment of vaginitis, the adherence of Lactobacillus species to normal human vaginal epithelial cells was tested by in vitro methods. L. acidophilus and L. bulgaricus isolated from three commercial yogurts were compared to L. acidophilus, L. fermentum, L. cellobiosus, and L. casei isolated from clinical specimens and from American Type Culture Collection cultures. L. acidophilus isolated from Lactinex tablets was also tested. No significant difference was found among the 19 clinical isolates, the American Type Culture Collection cultures, and the Lactinex isolate, but all showed significantly higher (p less than 0.01) adherence than any Lactobacillus isolated from yogurt. The presence of Gardnerella vaginalis, which adheres strongly to vaginal epithelial cells, was found to interfere with the adherence of lactobacilli from all sources studied.

Delayed cutaneous hypersensitivity (DCH) of 12 normal adult subjects to purified protein derivative (PPD) of Mycobacterium tuberculosis , streptococcal streptokinase-streptodornase (SK-SD), and Candida albicans Dermatophytin O (DO) was assayed in vivo by skin testing and compared with such in vitro correlates of cellular immunity as lymphocyte transformation (LT) and inhibition of leukocyte migration (ILM) from microcapillary tubes or in agarose gel. LT was shown to be the best in vitro correlate of specific lymphocyte sensitization with all antigens. In the ILM assays, PPD showed good correlation with in vivo DCH and in vitro LT; SK-SD showed partial correlation; DO showed no correlation, not being active in any of the ILM tests. Cell distribution and morphology of stained migration patterns, ILM tests performed on separated populations of lymphocytes and polymorphonuclear leukocytes (PMN), as well as the ability of test antigens to stimulate PMN cells to reduce nitroblue-tetrazolium dye, indicated that in ILM tests mononuclear cells were not inhibited in their migration, whereas migration of PMN cells appeared to depend on their direct reaction with the test antigens.

• Endocarditis in a 2-year-old child was caused by a penicillin-resistant Streptococcus constellatus . Viridans streptococci in general and those associated with endocarditis in particular are usually believed to be penicillin sensitive. Although the patient did not receive prophylactic antibiotics, the child had recently been treated with an oral penicillin. Penicillin-resistant viridans streptococci are usually sensitive to the synergistic effects of penicillin and an aminoglycoside, but this organism was not. Clindamycin was ultimately shown to demonstrate admirable bactericidal activity against this patient's S constellatus . ( Am J Dis Child 1982;136:42-45)

• We performed autopsies and serologic tests in 189 subjects (152 men and 37 women) between 20 and 50 years of age with no history of immunosuppression who died unexpectedly and whose bodies were referred to the San Francisco coroner's office. Forty-eight of the 88 single men for whom addresses were available lived in areas of the city with a high incidence of the acquired immunodeficiency syndrome (AIDS). In addition, 36 of the subjects (30 men) were intravenous drug abusers. Antibody to the retrovirus associated with AIDS was present in 23 (18%) of the 121 subjects whose sera were tested. However, neither pathologic nor laboratory manifestations of AIDS were present in any of the 189 subjects who underwent autopsy. These results suggest that antibody to the retrovirus is common but subclinical manifestations of AIDS are uncommon in San Francisco, a city where the incidence of clinical AIDS is high. (Arch Intern Med1986;146:713-715)